Katie Kloss LMT 900 NW 8th Avenue Gainesville, FL 32601 352.328.

9971

Massage Therapy Intake Form

Name __________________________________________________ Date ___________________________

Address __________________________________________________________________________________ Street City State Zip Date of Birth __________________ Occupation __________________ Phone # ____________________

Emergency Contact _________________________________________________________________________ Name Relationship Phone Number

What are your goals and/or expectations for this therapy session?

Have you ever received massage or other bodywork before? If yes, please describe your experience:

Yes

No

Are you currently taking any medications or supplements? If yes, please explain:

Yes

No

Have you ever had surgery and/or been hospitalized for any reason? If yes, please explain:

Yes

No

Have you suffered any major injuries in the past five years? If yes, please explain:

Yes

No

Are you currently seeing a physician, physical therapist, or chiropractor for any ongoing issue? If yes, please explain:

Yes

No

Do you have any allergies and/or skin sensitivities? If yes, please explain:

Yes

No

Do you have any restrictions or limitations that would affect your ability to receive massage? If yes, please explain:

Yes

No

Are there any specific areas of your body that you would like me to focus on? If yes, please specify:

Yes

No

Are there any specific areas of your body that you would like me to avoid? If yes, please specify:

Yes

No

Are you currently experiencing any pain?

Yes

No

If yes, please rate your current pain level on the following scale: 0 1 2 3 4 5 6 7 8 9 10 Yes No

Are you currently experiencing any stress?

If yes, please rate your current stress level on the following scale: 0 1 2 3 4 5 6 7 8 9 10

Are you wearing contact lenses? Are you wearing a hearing aid? Are you wearing dentures? Do you have a pacemaker? Are you taking any blood thinners? Do you bruise easily? Are you currently pregnant?

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No _________ weeks

Please indicate all of the following conditions that apply to you (past or present). Y N anemia anxiety asthma autoimmune condition back pain blood clots broken bones bruxism bursitis cancer cardiovascular disease carpal tunnel syndrome chemical dependency (drugs/alcohol) chronic fatigue chronic pain constipation Crohns disease depression diabetes dizziness edema epilepsy fibromyalgia headaches heart attack hemophilia hepatitis herpes simplex high blood pressure HIV/AIDS IBS Y N insomnia low blood pressure lupus migraines multiple sclerosis muscle strain/sprain neuropathy numbness/tingling osteoarthritis osteoporosis panic disorder paralysis Parkinsons disease plantar fasciitis psoriasis PTSD respiratory issues rheumatoid arthritis sciatica scoliosis seizures shingles sinus problems stroke tendonitis thrombosis TMJ disorder/dysfunction tuberculosis varicose veins whiplash other __________________

Please use the space below to explain all YES answers:

I, _____________________________________, voluntarily consent to receive therapeutic massage services, including any related modalities within the scope of practice of my licensed massage therapist. I affirm that all of the information I have provided in this agreement is true and accurate to the best of my knowledge. I assume full responsibility for notifying the therapist of any changes to my physical and/or mental health that may occur at any point during the course of treatment. I hereby waive and release my therapist and any affiliated massage establishments and/or entities from all liability (past, present, and/or future) relating to massage therapy and/or bodywork. I understand that my personal health information and any other client records maintained by my therapist are private and confidential. I understand that my information will not be disclosed or released to any third party without my prior written consent or a subpoena or other court order. I understand that massage therapists are not physicians and that massage therapy should not be construed as a substitute for medical examination and/or treatment provided by a licensed physician. I understand that massage therapists do not diagnose any physical or mental illnesses, that they do not prescribe any medical treatments or drugs/medications, and that they do not perform any spinal or skeletal manipulations. I understand that any and all information provided to me by my therapist is strictly intended for general educational purposes only and is not diagnostically prescriptive in nature. I understand that payment is due in full at the time of service unless otherwise specified by the therapist. I agree to pay for each session with either cash or a credit/debit card (Visa, AmEx, Mastercard, Discover). I understand that my massage therapist does not accept checks as a form of payment. I agree to adhere to the following rates for each session unless otherwise specified by the therapist: $35 / 30 minutes $65 / 60 minutes $95 / 90 minutes I understand that if I am late for an appointment, the length of that session will not be extended. I agree that I will still be liable for the full payment of that appointment. If I need to cancel or reschedule an appointment for any reason, I agree that I must contact my massage therapist at least 24 hours before my scheduled appointment time in order to avoid being charged a fee. I understand that I will be responsible of the full value of the missed appointment. Emergency circumstances will be considered on an individual basis. I understand that massage therapy is strictly professional in nature. I agree that any form of misconduct on my behalf, including but not limited to any sexually suggestive or otherwise inappropriate remarks and/or gestures, will absolutely not be tolerated. I understand that any such misconduct will result in the immediate termination of the session. I understand that I will be held accountable for the full payment for the terminated appointment and that I will not be allowed to book any future appointments at this establishment. I affirm that I have carefully read this agreement in its entirety and that I fully understand and agree to all of the terms and conditions enumerated therein. I acknowledge that I am signing this legally binding document on my own free will. ____________________________________________ Client Signature ____________________________________________ Therapist Signature _________________________________________ Date _________________________________________ Date